Occurrences at Los Alamos National Laboratory: What can they tell us?

The authors analyzed the evolution of institutional and facility response to groups of abnormal incidents at Los Alamos National Laboratory (LANL). The analysis is divided into three stages: (1) the LANL response to severe accidents from 1994 to 1996, (2) the LANL response to facility-specific clusters of low-consequence incidents from 1997 to 1999, and (3) the ongoing development of and response to a Laboratory-wide trending and analysis program. The first stage is characterized by five severe accidents at LANL--a shooting fatality, a forklift accident, two electrical shock incidents, and an explosion in a nuclear facility. Each accident caused LANL and the Department of Energy (DOE) to launch in-depth investigations. A recurrent theme of the investigations was the failure of LANL and DOE to identify and act on precursor or low-consequence events that preceded the severe accidents. The second stage is characterized by LANL response to precursor or low-consequence incidents over a two-year period. In this stage, the Chemistry and Metallurgy Research Facility, the Los Alamos Critical Experiments Facility, and the Los Alamos Neutron Science Center responded to an increase in low-consequence events by standing down their facilities. During the restart process, each facility collectively analyzed the low-consequence events and developed systemic corrective actions. The third stage is characterized by the development of a Laboratory-wide trending and analysis program, which involves proactive division-level analysis of incidents and development of systemic actions. The authors conclude that, while the stages show an encouraging evolution, the facility standdowns and restarts are overly costly and that the institutional trending and analysis program is underutilized. The authors therefore recommend the implementation of an institutional, mentored program of trending and analysis that identifies clusters of related low-consequence events, analyzes those events, and develops systemic actions to avoid both severe accidents and standdowns